**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure adequate supervision was provided to prevent elopement for 2 (Resident #30 and #126) of 3 (Resident #30, #48, and #126) sampled residents who were at high risk for elopement. This failed practice resulted in Immediate Jeopardy that caused or was likely to cause serious harm, injury, or death to Resident #30 and #126 who eloped from the facility. The Administrator, Director of Nursing (DON), and Consultant were informed of the Immediate Jeopardy on 9/21/22 at 3:21 PM. This failed practice had the potential to affect 8 residents who were an elopement risk per the list provided by the Administrator on 9/22/22 at 12:40 PM. The findings are: 1. Resident #30 was admitted to facility on 7/15/22 with diagnosis of Multiple Myeloma not having achieved remission, Chronic Diastolic (Congestive) Heart Failure, Hypertensive Heart Disease with Heart Failure and Anxiety Disorder. The admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/22/22 documented resident scored 11 (8-12 indicates moderate impairment) on the Brief Interview for Mental Status (BIMS) and independent with bed mobility, transfer, dressing, eating, toilet use, and personal hygiene. a. On 8/16/22 Resident #30 left the cottage to go to the main building to look for her nurse. The resident went to the end of 200 hall in the afternoon to look for her nurse. b. The 8/17/22 at 2:30 p.m. Nursing Note documented, Note Text: Resident has been wandering and walking around facility for most of the shift resident has been more confused than normal as well, resident showing signs and symptoms (s/s) of increased anxiety/anxiousness, resident is worried that staff is out to get her, resident called daughter and daughter came to visit with resident, daughter stated that she needs her anxiety medication, this nurse call Advanced Practice Registered Nurse (APRN) who stated okay to give One time only dose of Alprazolam 0.5 Mg [milligrams] 2 tablets PO [By Month], and to obtain a UA (urinalysis) with C&S [culture and sensitivity] on resident, Orders processed by this nurse, will continue to monitor. c. The 9/6/22 at 11:32 p.m. Nursing Note documented, Note Text: Elder stated (I have been thinking about kill myself, and that scares me. I don't want to kill myself. But I can stop thinking about it) After talking with her, she does not have a plain, for suicide. Reported to [Name] APN (Advanced Practice Nurse). d. The 9/7/22 at 7:51 p.m. Nursing Note documented, Note Text: Resident is currently on 15 min (minute) safety checks r/t [related to] stating she wants to kill herself. Stated she did not have a plan. Resident was also attempting to elope today. Resident called 911 twice earlier today stating that there was people painting on her antique tables and she wanted them out of her house. She has been stating that we need to get all the children and people who do not belong there out of her house. She has been pacing and crying all shift. PRNs [As needed] administered and noted effective at this time. Resident is currently resting in bed. Respirations even and unlabored. Will continue to monitor and make note of any changes. e. An Office of Long-Term Care (OLTC) Witness Statement Form dated 9/12/22 at 3:45 p.m. and signed by Certified Nursing Assistant (CNA) #4 documented, Witness Full Name [Name] Job Title [CNA] .I, [Name] was leaving [Business name] after my shift and seen [Resident name] behind the cottages walking. By the time I was able to turn around she had already made it almost to [Business name] I pulled into [Business name], got out of my ear and tried to redirect her. She wasn't having it. I asked if anyone knew she had left, she said no. She got into [Business name] and held the door shut so I couldn't get in. Once I got in another CNA got there to help. [Resident name] was telling [Business name] staff that her chest was hurting. Our administrator got there and also tried to talk to her and redirect her. Our administrator had to call her family. [Resident name] was my eyesight the whole time. I watched her leave from our facility ground to [Business name]. f. An OLTC Witness Statement form dated 9/12/22 at 4:05 p.m. and signed by the Certified Nursing Assistant (CNA) #6 documented, Witness Full Name [Name] Job Title [CNA] . I was vacuuming, and CNA #7 was in the kitchen I looked up and I remember her standing by the island by the TV, but I never heard the door open or close because of the vacuum. But we never thought she would run away because she likes to sit outside and read but [DON Name] and [ADON name] came over to let us know what was going on. g. The 9/12/22 at 7:49 p.m. Nursing Note documented, Note Text: [Name], CNA (Certified Nursing Assistant) came into DON office and stated that [Name], CNA had just called her and stated that resident, [Resident name] was seen by [name] going around the fence between our facility and [Business name] parking lot. [Name] states that when she saw the resident, she was still on facility grounds, and she had the resident in her sight. Administrator called [name], resident's daughter, to help assist returning resident safely to the facility. Once safely returned to facility resident assessed with temp, 98.4, in normal limits and no negative findings noted. Resident's family member is to stay with resident tonight. Resident to be transitioned to main traditional home tomorrow. Hospice notified of situation. [Name], APRN notified via telephone. h. An OLTC Witness Statement form dated 9/13/22 at 10:00a.m. and signed by Resident #30 documented, Witness Full Name [Name Resident #30] Job Title [None listed] .Relation to Resident (if Any) Self .I was running away, because I was afraid. Because I was in a business of what, I can't remember. i. An OLTC Witness Statement form dated 9/12/22 and signed by Licensed Practical Nurse (LPN) #1 documented, Witness Full Name [Name] Job Title [CNA] . I was passing medication on 200 hall in main building during the time of resident wandering from cottage 2. j. The Care Plan initiated on 9/13/22 documented, . [Name] scored 4 on Wandering Risk scale, she is not a risk for elopement at this time. 9/12/22 Elopement attempt was made 9/13/22 Moved to main building . k. On 9/19/22 at 1:38 p.m. The resident's family notified the surveyor, One night mom had to come over to the building from the cottage to get some medication because the nurse was in the main building and not the cottage. l. An OLTC Witness Statement form dated 9/16/22 at 9:20 a.m. and signed by the Certified Nursing Assistant (CNA) #7 documented, Witness Full Name [Name] Job Title [CNA] On 9/12/22 I had been in the kitchen cooking and went to answer the call light in room [ROOM NUMBER]-3. When walking past the window I seen [Resident name] outside walking on the porch. She would walk around on the porch off and on during the day. When I came out of room [ROOM NUMBER]-3, I had learned then that [Resident name] had wandered off. m. On 9/20/22 at 8:19 a.m. The Surveyor asked the Certified Nursing Assistant (CNA) #4, Can you tell me what information you have regarding [Resident name] going over to [Business Name]? CNA #4 stated, I was off work. I got off at 2:00 p.m. I went to get my kids when they got out of school. I had to go to [Business name] to get my children some prescriptions. I was leaving [Business name] and I seen her walking from Cottage 2 over to Cottage 1. I tried to keep an eye on her as I was leaving. She was on the curb trying to cross over to the other side of the drive. I pulled turned left onto the highway and then turned left into the facility to turn around. When I got back over, she was at [Business name] in the grassy part in front of the building. I met up with her and told my kids to stay in the car. When I got out, I was trying to talk to her and asked if she told anyone she was gone. She stated, no I didn't but I probably should have. I was walking with her to the [Business name] door and I was on the phone with CNA #5. I asked CNA #5 if anyone knew [Resident name] was in [Business name]. I called the ADON and then I seen the Administrator's trying to get to his truck. I turned around for one second and [Resident] went into the [Business name] and closed the doors. She held the doors closed shut and I could not get in. I finally made my way into [Business name] and another CNA was in the building as well. That was when the Administrator pulled up. The Administrator took over everything from there and I came back to the facility and wrote my witness statement. The Surveyor asked, Do you know what time this occurred? CNA #4 stated, 3:30-3:45pm. The Surveyor asked CNA #4, Has the resident ever done something like this before? CNA #4 stated, No she would always set outside on the front porch or walk around the cottages, but she has never left before. n. On 9/20/22 at 8:33 a.m., The Surveyor asked CNA #5, Can you tell me what information you have regarding [Resident name} going over to [Business name]? CNA #5 stated, I was on the phone with [CNA #4] and I was leaving work. My children get off the school bus here. They were already with me, and I was leaving, and CNA #4 stated, [Resident name] was in the parking lot of [Business name]. I turned back into the facility, and I ran in and told DON and ADON. They jumped up and ran to the Cottages. CNA #4 stayed with the resident until the Administrator got there. I went over to the cottage to help the staff check on the residents then I left because, I had my kids with me. o. On 9/20/2022 at 11:02 a.m., an Inservice was provided by the facility, with 36 staff signatures completed on 9/12/22. It documented, .Elopement/Elopement attempts/ Exit seeking or shaking the door ., If any of the above has occurred or occurring, you should immediately do these steps every time: Inservice staff on elopements after any elopement attempt immediately after ensuring all other elders are accounted for and the missing elder is back in the home ., 1. Do a head count/census count to ensure al are accounted for and are safe? ., 2. Do a perimeter check to insure all elders are accounted for and are safe and are not outside ., 3. Search every office, closet, supply closet, locked doors, refrigerators, every nook and cranny to ensure all elders are accounted for and or safe ., 4. Do door checks on every exit door to ensure all exit doors are secured and alarms are functional ., 5. Do an elopement assessment on all elders and ensure the assessment is correct. Do not use old scores. If all post elopement assessments were completed within 30 minutes, there is something wrong ., 6. Ensure that the elopement binder at the nurse's station is up to date. Any elder that exit seeks, attempts to elope or shakes the doors should have a up to date picture that shows their entire body. If they ambulate-the picture needs to show them standing with whatever device is in use. If a Wheelchair is in use, the picture should include that .,7. An elopement assessment should be completed on every elopement attempt, even if unsuccessful. Any time an exit seeker shakes the door, one should be completed ., 8. Care plans should address any elopement a score of 5 or higher. If their score is above 5, but doesn't exit seek, doesn't express a desire to go home, then the care plan needs to address that the elopement score if high because they are on numerous medications. 1 point is given for every medications that is checked .,9. Every exit door should have some type of alarm on it. If there isn't one, obtain a smart alarm from Walmart or closest store available as soon as possible and place it on the exit door .,10. All staff needs to in serviced on elopements, attempted elopements, exit seeking behavior and any resident that shakes the door are considered to be an elopement risk and should be treated as such ., 11. All staff need to be in serviced on responding immediately to an alarming door ., 12. The administrator, DON [director of nursing] and or ADON [assistant director of nursing] should be notified immediately ., 13. Follow your specific missing resident/elopement protocols in notifying police, family, etc. [etcetera] or as otherwise instructed by the administrator ., 14. Review every admission/readmission assessment for their elopement score and any that have expresses desire to go home and /or exits seeks; initiates steps immediately to prevent elopement from occurring . p. On 9/20/22 at 11:19 a.m. The DON provided a statement and it documented, On September 12, 2022, at approximately 1600 (4:00 PM, I, [Name] RN/DON [Registered nurse/Director of Nursing] and [Name] LPN/ADON [Licensed Practical Nurse/Assistant Director of Nursing] pulled a complete census report we rounded on all elders in the cottages and checked the cottage doors for proper locking and alarm functions as well as a perimeter check. Next, I, [Name] RN/DON [Registered nurse/Director of Nursing] completed rounds on all elders in the traditional building while checking doors for proper locking and alarm functions as well as a perimeter check. q. On 9/20/22 at 3:54p.m., The Surveyor asked the DON [Director of Nursing], Are you aware of the resident coming over here during a rainstorm one night looking for her nurse? DON stated, No, I have never heard of that. The Surveyor asked, Are you aware of a day when the resident walked over to the building from the cottage to get medication from her nurse? DON stated, I do know she come over to the building looking for her nurse. She would walk around the cottages yard and would set outside a lot of the time. The Surveyor asked, Can you tell me what occurred that day on 8/16/22 that the resident walked over to the building looking for her nurse? The Surveyor asked, What was done to prevent resident from leaving the cottage and returning to the traditional building? DON stated. I educated the resident and the Nurse. The Surveyor asked the DON, Can I see the documentation you have for the education? DON stated, I done the education verbally and there was no documentation. The Surveyor asked, Do your nurses work the cottages and building at the same time? DON stated, Yes. r. Review of Resident #30's medical chart showed no documentation of the occurrence. 2. Resident # 126 was admitted on [DATE] with diagnoses of Malignant Neoplasm of Esophagus, Unspecified, Adult Failure to Thrive, Malignant Neoplasm of Upper Third of Esophagus, Barrett's Esophagus with High Grade Dysplasia and Severe Protein-Calorie Malnutrition. The admission Minimum Data Set (MDS) has not been completed. A Brief Interview for Mental Status (BIMS) was completed on 9/14/22 and resident scored 15 (13-15 indicates cognitively intact). The admission Evaluation dated 9/13/22 documented resident was independent with bed mobility, eating, ambulation, toileting, and required supervision with dressing and personal hygiene. a. On 9/13/22 The admission Evaluation documented, .B. Wandering Risk Scale .1. The resident is comatose, and/or dependent on Activity of Daily Living (ADL)S and cannot move without assistance, and/or is stuporous b. no. Mental Status 2. The resident: 1. Can follow instructions. Mobility 3. The resident: 3. Is ambulatory Speech Patterns 4. The resident: 0. Can communicate History of Wandering 5. The resident: 0. Has no history of wandering. Diagnosis 6. The resident has: 0. NO diagnosis of dementia/cognitive impairment; diagnosis impacting gait/mobility or strength .Wandering Risk Sale Score 4.0 . b. The Care Plan initiated on 9/19/22 documented, . [Resident name] scored 4 on Wandering Risk Scale, she is not at risk to elope at this time .Wandering risk Assessment as indicated, observe for any changes in mobility, exit seeking or wandering behaviors .Ambulation: Resident #126 is independent with ambulation .LOCOMOTION: Resident #126 is independent with locomotion .9/18/22 Observe for unsafe practices, cue for safety as needed. Encourage her to wear appropriate footwear, assist as needed. c. The 9/20/22 at 3:45 pm, Nursing Note documented, Nature/Description of Incident: CNA (Certified Nursing Assistant) reported that she was sitting at the table near the front door and witnessed resident walking to the door from the front porch pulling her wheelchair behind her and as resident was approaching the door, the CNA got up to meet her, and residents wheelchair began to roll backwards and resident grabbed her wheelchair and sat slowly to the ground in a crisscross legged fashion without hitting her head. Staff stated that resident's right buttocks touched the ground first and resident was continuously asking CNA not to report incident. CNA reported that she told resident that the incident had to be reported. As the nurse approached the resident outside at the front door, she was sitting on the ground holding on to the left side arm rest of her wheelchair with her right hand. Resident was assisted to a standing position and was resistive when this nurse and CNA was attempting to help her into her wheelchair. This nurse assisted resident to her room and observed resident for injuries with CNA at side. When this nurse asked resident what happened, she responded My wheelchair rolled backwards, and I couldn't grab it so I sat down. Resident stated that she sat down and did not fall. No new s/sx (signs/symptoms) of injuries from current fall. There was no redness noted and she denied pain . d. The 9/20/22 at 10:30 pm Nursing Note documented, Note Text: CNA reported to me. Resident was trying to leave the facility, when trying redirect resident. She stated If you don't leave me alone you will have to call the ambulance for yourself. Because I'm going to hurt you bad. e. The 9/21/22 at 6:41 am Nursing Note documented, Note Text: CNA reported elder was demanding to go to the Kitchen. When CNA explained the kitchen was closed and locked. She stated, I can go anywhere I want, and if you try to stop me, I will break the door down. f. The 9/21/22 at 9:00 am, Nursing Note documented, Note Text: Elder noted to be up stumbling around in her room. This nurse asked elder to please sit down and use her wheelchair (w/c) for mobility until she is stronger. Elder has had multiple falls and staff do not want her to get hurt. Elder was also asked to continue working with therapy to build her strength. Elder stated I am not crazy. Elder reassured that no one had said she was crazy, and she was asked to use the w/c because she is still weak and needs to build her strength up. Elder's room noted to have things strewn all over as well as liquid in the floor. Staff attempted to clean it up but elder was uncooperative. g. On 9/21/22 at 11:07am the Administrator was walking quickly down 200 Hallway pushing a wheelchair. The [NAME] Office Manager (BOM) swiftly walked back into the building. This Surveyor looked out the front door and observed a police car in the road with flashing lights and traffic was backed up. The Surveyor walked out the front door to the grass area between the road and the building and met the Administrator. The Surveyor asked the Administrator, What is going on? The Administrator stated, The Director of Nursing (DON) is on the phone calling for [Ambulance Service Name] to transfer her out for a psych (psychological) eval (evaluation). The Surveyor asked the Administrator, How did she get out? The Administrator stated, She [Resident] knows the code to the building and now she [Resident] is refusing to come back in. h. On 9/21/22 at 11:15am, the Resident was sitting in the back of a police car with her legs out the door and her feet on the road talking with Bystander #2 and the police refusing to come back into the facility. i. On 9/21/22 at 11:16am, Bystander #1 walked up to the Surveyor and stated, I am with the television stations and was leaving the reception and she [Resident] was just standing in the middle of the road. I saw Bystander #2 get out of her vehicle and walk up to the resident. Then a person came out of the building walking toward the resident and the resident started saying I am scared and would not let the employee come close to her. j. On 9/21/22 at 11:19 am, the Resident was loaded into the back of an ambulance by Emergency Personnel. k. On 9/21/22 at 11:20 am, Bystander #2 stated, I was driving down the road and I see this lady standing in the middle of the road. I went up to her and asked her if she was ok. The police stopped and we just started talking to her and was able to get her to set down in the car. She would not let anyone get close to her. l. On 9/21/22 at 11:24am, The Surveyor asked Certified Nursing Assistant (CNA) #3, Can you tell me what happened with Resident #126? CNA #3 stated, The BOM came out her office and said [Resident name] is outside. I darted outside and the police were already out there with her. The Surveyor asked CNA #3, Do you know how she got out? CNA #3 stated, She knows the code by her room so she must have gone out that door because she did not come through the front. m. On 9/21/22 at 11:25am, The Surveyor asked the BOM, Can you tell me what happened with Resident #126? The BOM stated, I got a phone call and the person said, Hey, I think one of your residents is out in the road trying to touch cars. I asked [CNA #3] is that [Resident #126] outside. She looked outside and said yes as she went out the front door. [Resident #126] was standing in the road and people were coming up to her [resident] and I started calling administration. n. On 9/21/22 at 11:30am, Nursing Incident and Accident report documented, Nature/Description of Incident: BOM ran to DON/ADON [Director of Nursing/Assistant Director of Nursing] office and stated that resident was on the highway trying to touch cars. DON, ADON, & Administrator immediately ran outside to resident where she was standing with a police officer, bystander, and CNA near the police officers' car in the turning lane in the middle of the road in front of the facility. Staff attempted to redirect resident back to facility, and she refused. She told the police officer she wanted to get in his car and refused for staff to come near her. Resident refused to speak to staff and stated to the police officer, Please I don't want to go back there. I want to stay with you. I want to get in your car. Let me stay with you please. The DON immediately called APRN [Advanced Practice Registered Nurse] and received STAT [Without delay] telephone order to send resident out to ER [Emergency Room] for eval and treatment. Description of Injuries: Resident refused to talk to staff or allow staff to come near her, unable to observe for injuries or pain. Immediate Actions Taken: Sent to [Hospital Name] ER for evaluation and treatment o. The 9/21/22 at 11:31am Nursing Note documented, Note Text: At 11:26, resident was transported to (Named Facility) emergency room (ER) for eval and treatment via (Named Ambulance Company) accompanied by 2 EMS personnel.,(Named) mother, was notified of incident and transfer. She stated she lived a couple hours away and was unsure if she would be able to make it to the hospital and thanked this nurse for calling. p. The 9/21/22 at 12:30pm Nursing Note documented, Note Text: Last night at approximately 1915, resident was noted to be yelling [Name]. Resident was noted to be in her wheelchair at her room doorway. Enquired who [Name] was and she stated my friend up there, referring to another resident. Resident stated that she had fell and no one was taking care of her. Explained to resident that we were taking care of her and that is why we were checking her vitals and neuros (neurological status). Resident's neuros noted to be WNL [Within normal limits]. Also explained to resident that we had contacted [Name], APRN [Advanced Practice Registered Nurse] and had received order to send her to the ER [Emergency Room] for evaluation. She responded that we were taking too long and asked if she needed to call 911. She said, I want [Name] to call all my doctors to check this place out. Explained that we were calling the ambulance to come get her. [Resident name] was then escorted via wheelchair to DON office while report was being called to [Hospital Name] ED [Emergency Department] and [Ambulance Service Name] per [ADON Name]. [ADON name] asked resident if there was anyone that she would like for us to call and she said [Name]. [ADON] attempted to call [Name] without success x2 attempts. Asked resident if there was anyone else, she would like to notify and she said her mother. Her mother was called at approximately 1921 [7:21p.m.]and resident yelled to put her on speaker phone while ADON was attempting to explain situation. Resident stated, My room is inhumane, but you know how nasty I am. Mom I am confused at this place. Mother, [Mother Name], replied to resident you don't think properly when you need to get some rest. After phone call resident was mumbling to herself repeatedly I am so sorry ya'll are not taking care of me. Asked what we are not doing to take care of you, and she replied everything. Asked to explain what she meant, and she would only reply everything. [Ambulance Service Name] arrived at office at 1930 [7:30p.m.] Resident's PEG [Percutaneous Endoscopic Gastrostomy] was flushed and disconnected from continuous feeding. She was assisted onto the stretcher, and she was telling [Ambulance Service Name] that we don't take care of people here. Female paramedic was noted to stated that she has only seen us take care of people and we were nice. Resident in care of [Ambulance Service Name] x2 and exited facility at 1943 (7:43p.m.). q. The 9/21/22 at 1:42pm note documented, Note Text: At approximately 0820 this morning spoke with [Name] APRN regarding information obtained from resident's parents during phone call last evening regarding resident's past behavioral issues, her attention seeking behaviors, and past drug abuse. No new orders received at this time. The 9/21/22 at 9:12PM Nursing Note documented, Note Text: Spoke with RN at (Named Hospital) and resident was admitted to (Named unit) for weakness and elevated troponin. r. An Office of Long-Term Care (OLTC) Witness Statement form dated 9/21/22 and signed by the Certified Nursing Assistant [CNA] documented, Witness Full Name [Name] Job Title [CNA] .Did my 15 minutes at 11:00am safety check on [Resident name], she was still in her bed. I came to relief [Name] at the door. Name BOM, came and told me [Resident name] was outside in the road. I ran out the door to be with her until nurse or department head could arrive on scene. s. An OLTC Witness Statement form dated 9/21/22 at 11:50a.m. and signed by the BOM documented, Witness Full Name [Employee name] Job Title [Billing Office Manager] .I received a phone call on facility phone around 11:05am. Caller stated, I think one of ya'll resident is out in the highway trying to touch cars. I said, Thank you. I ran outside to look but couldn't quite tell. I came back to the door and asked [name] to look, which she did, and she said it was her. She went on out to the road, and I ran in to the DON [Director of Nursing] office to tell Administrator, DON, and ADON who then rushed outside. t. On 9/21/22 at 5:13pm, the plan of removal was accepted. u. On 9/23/22 at 8:25am, The Surveyor asked the DON, Were there any revisions made to [Resident Name] care plan on Tuesday after her verbalizing wanting to leave the facility? DON stated, I would have to look at her care plan. The Surveyor asked, When do you revise your facility care plans? DON stated, They are done after our morning meetings. The Surveyor asked, Who is responsible for revising care plan? DON stated, The MDS [Minimum Data Set] Coordinator. v. On 9/23/22 at 8:47am, The Surveyor asked MDS Coordinator #1, Did you make any revisions to [Resident name] following her verbalizing wanting to leave the facility on Tuesday? MDS Coordinator #1 stated, No, I did not. The Surveyor asked MDS coordinator #1, When do you revise care plans? MDS Coordinator #1 stated, Usually after morning meeting and we are able to go over everything. That Wednesday morning, I was working a medication cart on the floor so I would not have made any changes to the care plan. MDS Coordinator pulled up the resident's care plan on her computer and stated, Sometime that day after she eloped, it looks like I update her care plan after they completed a new wandering risk assessment. w. On 9/23/22 at 8:52am, The Surveyor asked MDS Coordinator #2, Did you make any revisions to [Resident name] following her verbalizing wanting to leave the facility on Tuesday? MDS Coordinator #2 stated, No, I did not The Surveyor asked, When do you revise care plans? MDS Coordinator #2 stated, The same as her. After we go over things in the morning meeting or I will change it throughout the day as the orders change. The Surveyor asked, Were there changes to [Resident name] care plans that needed to be made? MDS Coordinator #2 stated, I am not even sure we had a morning meeting on Wednesday. The Plan Of Removal for Resident #126 was provided by the Administrator on 09/21/22 at 4:59 PM reads as follow: Preperation and/or execution of this plan do not constitute admission or agreement by the provider thta immediate jeopardy exists. This response is also not to be construed as an admission of fault by the facility, its empoyees, agents or other individuals who draft or may be discussed in this response and immediate jeopardy removal plan. This immediate jeopardy removal plan is submitted as the facility's immediate actionable plan to remove the likelihood that serious harm to a resident will occur, or reocur. 1. Identification of Residents Affected or Likely to be Affected: The facility took the following actions to address the citation and prevent any additional residents from suffering an adverse outcome. (Completion Date: 9/21/2022) Residents directly involved in this deficient practice had their care plan reviewed and updated by the DON or designee and updated to reflect current wandering and elpement risk. The MDS Coordinator reveiwed Section E of the MDS and associated CAA for all residents. Care Plans were reviewed and updated to ensure they reflect audit findings, Concerns were not identified. MDS Coordinator/Designee re-evaluated residents at risk for wandering using an wander risk assessment tool. All nursing staff currently shiftswill be educated on wandering, elopement, and resident safety from the DON and designee(s). Any staff on leave will receive education on their next scheduled work day. 2. Actions to Prevent Occurence/Reoccurence: The facility took the following actions to prevent an adverse outcome from reoccuring. (Completion Date: 9/21/22) Elopement and wandering resident's policy was reviewed. The DON or designee will audit new admissions for elopement risk and ensure appropriate interventions are in place. The DON or designee will audit compleded MDS's to ensure the care plan reflects needs/concerns identified in the CAAs. New hires will receive education on wandering, elopement, and resident safety by the DON or d